becaplermin gel (Regranex®)

Prior Authorization Call Line: 1-877-309-9493

Prior Authorization Fax Line: 1-800-268-2990

Prior authorization for becaplermin gel (Regranex®) has been implemented to reinforce appropriate use and to ensure utilization
consistent with the approved indication. Requests for prior authorization of becaplermin gel (Regranex®) can be initiated
by either prescribers or their authorized agents. An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i.e. nurse, medical assistant).

Prior authorization requirements:

Prescribers, or their authorized agents, are required to respond to a series of questions that identify the prescriber, the patient and the reason for prescribing this drug.

Prescriptions can be written for a maximum of one 15 gram tube with no refills. There is a maximum of two 15 gram tubes in a lifetime.